Ann Thorac Surg 2000;70:738-741
© 2000 The Society of Thoracic Surgeons
Original articles: cardiovascular
Repair of cardiac defects through a shorter right lateral thoracotomy in children
Ying-long Liu, MDa,
Hong-jia Zhang, MDa,
Han-song Sun, MDa,
Shou-jun Li, MDa,
Jun Yan, MDa,
Jun-wu Su, MDa,
Cun-tao Yu, MDa
a Department of Cardiovascular Surgery, Fu Wai Cardiovascular Institute and Cardiovascular Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Address reprint requests to Dr Liu, Department of Cardiovascular Surgery, Fu Wai Cardiovascular Institute and Cardiovascular Diseases Hospital, A167, Beilishi Rd, Xicheng District, Beijing 100037, Peoples Republic of China
 |
Abstract
|
|---|
Background. Median sternotomy is a conventional approach for correction of cardiac defects for many years; however, the cosmetic result is poor. Therefore, right lateral thoracotomy was tested as an alternative procedure with a better cosmetic outcome.
Methods. Between October 1994 and February 1999, 683 patients underwent correction of congenital cardiac malformations during a cardiopulmonary bypass through right lateral thoracotomy involving a shorter incision through the third or the fourth intercostal space. All of the patients were children. The average age was 3.26 ± 1.67 years (range, 4 months to 7 years). The average weight was 13.59 ± 4.37 kg (5 to 40). The patients had various cardiac defects and associated anomalies.
Results. Only 2 patients died after operation, 1 from low cardiac output and the other from severe pulmonary infection. The hospital morbidity was lower. The mean cardiopulmonary bypass time was 58.67 ± 35.11 minutes (range, 16 to 430 minutes), the mean aortic cross-clamping time was 35.03 ± 24.84 minutes (range, 3 to 205 minutes). The postoperative average mechanical ventilation time was 19.23 ± 39.11 hours (range, 2 to 391 hours), and the mean postoperative stay was 8.55 ± 12.54 days (range, 5 to 293 days).
Conclusions. The right lateral thoracotomy incision is a safe and effective alternative to a median sternotomy for correction of cardiac defects. Advantages of this approach compared with median sternotomy are less injury, maintenance of the continuity and the integrity of the bony thorax, and prevention of the development of "pigeon-chesting." The scar is less visible, hence, the cosmetic result can meet patient expectations. This procedure is consistent with the idea of minimal invasive surgery.
|
Introduction
|
|---|
Median sternotomy is a conventional approach for correction of cardiac defects for many years. But a midline scar may be unsightly and can easily provoke displeasure and psychological distress, especially in young female patients. As the safety of cardiac operation has increased, more emphasis has been put on cosmetic results after operation [1, 2]. Therefore, a right anterolateral thoracotomy has been used in selected cases, and the aesthetic result was preferable and accepted by many people. However, the indication was limited [2, 3].
We present our technique and results of correction of cardiac defects in a shorter incision through the right lateral thoracotomy in 683 patients. Our findings suggest that left cardiac anomalies in some cardiac deformities should not be contraindications for this approach.
|
Material and methods
|
|---|
From October 1994 to February 1999, 683 patients underwent heart operations through a right lateral thoracotomy approach (365 boys, 318 girls). At the time of operation, the mean age of these patients was 3.26 ± 1.67 years (range, 4 months to 7 years). The mean weight was 13.59 ± 4.37 kg (range, 5 to 40). In this series, all of the patients were younger than 7 years old (369 were younger than 3 years old) and 176 of the patients weighed less than 10 kg. The mean cardiothoracic (CT) ratio was 0.58 ± 0.06 (range, 0.42 to 0.83). All patients had definite diagnoses by physical examination, chest roentgenogram, and echocardiography. The different types of cardiac defects in this group included 162 secundum-type atrial septal defects (ASD), 403 ventricular septal defects (VSD), 65 tetralogy of Fallot (TOF), 16 partial endocardial cushion defects (PECD), 24 ASD plus VSD, 4 severe mitral regurgitation, 2 cor triatriatum, 2 obstruction of the left ventricular outflow tract, 2 pulmonary stenosis (PS), 1 double-outflow right ventricle (DORV), 1 left atrial myxomas (LAM), and 1 right ventricular fistulas from the left coronary. The types of cardiac anomalies and the procedures are listed in Table 1.
Operative technique was as follows: The patient was placed on his or her right side elevated 60 to 80 degrees. The right arm was suspended over the head and fixed to the frame to provide better relaxation of the pectoralis major muscle (Fig 1). A skin incision was made obliquely about 6 to 8 cm between the anterior and posterior axillary folds; the upper point was in the third intercostal space and the lower point was in the sixth. A flap of skin and pectoralis was dissected from the underlying chest wall and retracted cephalad, to enter the chest cavity through the fourth or the third intercostal space. Care was taken to preserve the lung. If the access was inadequate, we sometimes extended the incision anteriorly and transected the sternum. This, however, was not necessary in all of our patients. This technique avoided injuring the internal mammary artery and dividing the costal cartilage. Selection of the correct intercostal space was critical to obtaining adequate exposure. The lung was retracted posteriorly, the right lobe of the thymus was dissected. The pericardium was opened longitudinally 1 to 2 cm anterior to the phrenic nerve. The pericardial incision was extended superiorly and inferiorly, giving adequate exposure to the aorta and the inferior vena cava. Pericardial stay sutures were put on traction to elevate the mediastinal structures in the operative field. After the ascending aorta was placed with two concentric purse-string sutures and cannulated with the right-angled cannula, the superior vena cava was cannulated in the right atrial appendage with the right-angled cannula through a purse-string. The inferior vena cava cannula was inserted through a stab wound at the cavoatrial junction. In this series, aortic cannulation was accomplished without difficulty in all patients. Cardiopulmonary bypass (CPB) was established through these cannulas and core cooling was begun. When the body temperature was between 24°C and 32°C, the aorta was cross-clamped and cold crystalloid cardioplegic solution was infused into the ascending aorta. Acceptable exposure of the intracardiac anatomy could be obtained with a standard oblique right atriotomy or a vertical right ventriculotomy incision.
View larger version (105K):
[in this window]
[in a new window]
|
Fig 1. The posture of the patient is the right side elevated 60 to 80 degrees, and the right arm is suspended over the head and fixed to the frame. The skin incision is made obliquely about 6 to 8 cm between the anterior and posterior axillary folds.
|
|
The procedures for correcting the heart anomalies were almost the same as those for median sternotomy and are listed in Table 1. For the secundum-type ASD, VSD, continuous suture or patch (pericardial or Dacron patch) was directly used. For the patent ductus arteriosus (PDA), direct suture was used through the pulmonary artery incision under the lower temperature and the lower rate of perfusion. For the left superior vena cava (LSVC), it was dissected and cross-clamped intermittently if it was small, otherwise, it was cannulated through the coronary sinus. For TOF or the right ventricular outflow tract obstruction (RVOTO), two traction sutures were placed on the infundibulum in an area free of major coronary arteries, then two small cats-paw retractors were placed on each side of the ventriculotomy to provide good exposure of the right ventricle outflow and pulmonary artery (Fig 2). After closing the VSD with a Dacron patch and excising the heavy muscle bundles, the autologus pericardium or the homograft artery with single valve was used to widen the right ventricular outflow tract or the main pulmonary artery. This method could successfully eliminate the RVOTO caused by hypoplasia of both the infundibulum and the pulmonary artery, where a patch was sutured into the incision extending distally from the bifurcation of the pulmonary artery to slightly proximal to the infundibulum septum (for 3 patients who had a single coronary artery, we excised the pulmonary valve ring, and widened the pulmonary artery and right ventricular outflow tract by pericardium, respectively). For PECD, the prolapsed mitral valve was repaired through the ASD before ASD closure. For the mitral valve regurgitation, valvuloplasty methods were used through the atrial septal incision (the mitral valve replacement was used in 1 patient). For the obstruction of the left ventricular outflow tract, the subaortic membrane was dissected through the transverse aortotomy. For the left coronary to right ventricular fistula, suture ligation was employed. For the LAM, myxoma was excised through the right atriotomy, using an atrial septal incision.
View larger version (139K):
[in this window]
[in a new window]
|
Fig 2. The tetralogy of Fallot operative view of the right ventriculum opened from the right lateral thoracotomy approach. Aortic cannulation is performed smoothly. The ventricular septal defect and the aortic valves are exposed perfectly (arrow).
|
|
The air in the heart could be evacuated easily when the aortic clamp was released slowly and the aortic needle vent was connected to suction. Pediatric internal paddles were used for defibrillation in only 4 patients. The CPB was gradually discontinued. The pericardium was closed. The thoracic and pleuropericardial drain was placed. The chest was then closed in a routine fashion with an intradermic continuous suture (4-0 Prolene) for the skin layer. The mean CPB time was 58.67 ± 35.11 minutes (range, 16 to 430 minutes), the mean aortic cross-clamping time was 35.03 ± 24.84 minutes (range, 3 to 205 minutes). The postoperative average mechanical ventilation time was 19.23 ± 39.11 hours (range, 2 to 391 hours).
|
Results
|
|---|
There were only 2 patients who died of the operation: 1 from low cardiac output and the other from severe pulmonary infection. The postoperative complications of 18 patients included: 1 temporary neurologic deficit, 1 VSD residual shunt patient (reoperation through primary incision 2 days after operation), 1 delayed cardiac tamponade 3 days later after operation (treated with pericardial aspiration), 9 atelectases, 3 pareses of the right hemidiaphragm, 2 hemorrhages after operation, and 1 incision inflammation.
The mean amount of the thoracic and pleuropericardial drainage was 132.99 ± 99.10 mL (range, 5 to 753 mL), significantly lower than the amount associated with median sternotomy (180.07 ± 88.97 mL) (p < 0.01). Electrocardiogram showed that all patients were in normal sinus rhythm without atrioventricular block. Echocardiographic results after operation revealed no residual shunt. The wounds healed well. The mean hospital stay was 8.55 ± 12.54 days (range, 5 to 293 days).
The long-term follow-up was 12.3 ± 10.4 months (range, 6 to 45 months) in 589 patients. One patient died from respiratory failure because of asthma 6 months after the operation. A 3-mm residual shunt was discovered in 1 patient 3 months after the operation. It was unnecessary to operate on this patient because the heart was functioning well. The scar of the skin incision was obscured, and the development of the chest was nearly normal.
|
Comment
|
|---|
Despite the cosmetic disadvantage, median sternotomy has been the standard incision for most cardiac procedures. With the improvement of surgical technique, the operative mortality of some congenital heart disease (CHD) is close to zero, such as ASD, pulmonary stenosis, aortic stenosis, and so on. So more attention is dedicated to the aesthetic results of operation. Right thoracotomy is cosmetically more acceptable, particularly in young female patients [2–4], and is a safe and effective method in some CHD [2, 3] and reoperation [5–8]. Therefore, the right anterolateral thoracotomy approach is an alternative to median sternotomy. Most studies, however, have been conducted with teenagers or adults, and have mentioned many contraindications [2, 3], including pulmonary stenosis, severe pulmonary hypertension, age less than 2 years old, PDA, LSVC, and so on.
In our practice, most CHD have been corrected through right lateral thoracotomy in children (54% patients aged less than 3 years old). Good exposure and cannulation of aorta were the key steps, and could be performed safely. Cardioplegic arrest with aortic clamping was used. Exposure of intracardiac anatomic structures was acceptable, especially for pulmonary artery and right ventricular outflow tract. Confident exposure could be gained through retracting the heart posteriorly. The RVOTO was widened in 2 ASD, 11 VSD associated with RVOTO, and 65 TOF. The outflow patch was extended across the stenosis area of the main pulmonary artery in 41 patients. The morbidity of a residual defect and a residual pulmonary stenosis through our approach was almost the same as that of the median sternotomy, because our approach had the same defect exposure as the median sternotomy method and the standard of the correction was also the same. Much attention had to be paid to suturing the patch because of the difficulties in controlling hemorrhage. It was easy to remove air from the heart because the left ventricular apex was at the lowest point of the field, and continuous suction of the aortic vent was performed at the same time. Intracardiac anomalies coexisting with PDA and LSVC could be settled successfully in 22 patients and in 19 patients, respectively. There were no differences in the procedure of correcting PDA or LSVC between the right lateral thoracotomy and the median sternotomy approaches. There were no significant differences in CPB time, aortic cross-clamping time, ventilation time, and postoperative hospital stay. However, the amount of thoracic and pleuropericardial drainage was less through the right approach than through the median sternotomy (p < 0.01). The hospital morbidity was minimal.
The reason the indication for this approach was enlarged in our group was because the thoracic cavity was smaller and the elasticity of ribs was higher in the child than in the adult. The heart could be retracted posteriorly easily, providing good visualization. There was, however, no left pulmonary artery stenosis in our series. If the treatment of interventional occlusion of systemic-pulmonary collateral vessels was needed preoperatively, or the pulmonary artery developed very poorly (Ao:mPA > 4:1), or the presence, size, and continuity of native pulmonary arteries were not identified preoperatively, or the left pulmonary artery was abnormal as suggested by echocardiography preoperatively, the median sternotomy was also to be used. If this approach was used in TOF patients, the surgeon was required to have experience in correcting TOF through the median sternotomy and common congenital heart defects through this approach. We also agreed that if the CHD was more complex than TOF, or the chest roentgenogram indicated pleural thickening or adhesions between the right lung and the heart, the median sternotomy method would be used.
With the right lateral thoracotomy method, the scar was less visible and was almost completely obscured by the arm in adduction (Fig 3). In many studies, it was reported that axillary thoracotomy probably offered a smaller chance for breast or pectoral deformity [9]. The skin incision we designed was sited obliquely between the anterior and posterior axillary folds, further apart from the breast, so the breast development would not be affected without aesthetic problems. In this series, the results of the long-term follow-up indicated no impact on the development of the breast and pectoralis, and there was also no dysymmetry of the breast. Thus this approach can give an excellent cosmetic result. Advantages of this approach compared with median sternotomy also include less injury, maintaining the continuity and the integrity of the bony thorax, and preventing pigeon-chesting.
View larger version (112K):
[in this window]
[in a new window]
|
Fig 3. The child is a tetralogy of Fallot patient who underwent correction of cardiac anomaly. The scar of the skin incision is less visible and almost completely obscured by the arm in adduction.
|
|
In conclusion, it is believed that the right lateral thoracotomy can be performed safely in children for the majority of common CHD, including ASD, VSD, PECD, TOF, and so on. Congenital heart disease coexisting with PDA and LSVC are not contraindications to this approach. The cosmetic result is superior to that of median sternotomy or bilateral submammary incision, and this approach is consistent with the idea of minimal invasive surgery.
|
References
|
|---|
-
Lancaster L.L., Mavroudis C., Rees A.H., Slater A.D., Ganzel B.L., Gray L.A. Surgical approach to atrial septal defect in the female. Am Surg 1990;56:218-221.[Medline]
-
Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
-
Dietl C.A., Torres A.R., Favaloro R.G. Right submammarian thoracotomy in female patients with atrial septal defect and anomalous pulmonary venous connections. J Thorac Cardiovasc Surg 1992;104:723-727.[Abstract]
-
Massetti M., Babatasi G., Rossi A., et al. Operation for atrial septal defect through a right anterolateral thoracotomy. Ann Thorac Surg 1996;62:1100-1103.[Abstract/Free Full Text]
-
Praeger P.I., Pooley R.W., Moggio R.A., Somberg E.D., Sarabu M.R., Reed G.E. Simplified method for reoperation on the mitral valve. Ann Thorac Surg 1989;48:835-837.[Abstract]
-
Tribble C.G., Killinger W.A., Harman P.K., Crosby I.K., Nolan S.P., Kron I.L. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve. Ann Thorac Surg 1987;43:380-382.[Abstract]
-
Berreklouw E., Alfieri O. Revival of right thoracotomy to approach atrio-ventricular valves in reoperations. Thorac Cardiovasc Surg 1984;32:331-333.[Medline]
-
Szarnicki R.J., Stark J., de Leval M. Reoperation for complications after inflow correction of transposition of the great arteries. Ann Thorac Surg 1978;25:150-154.[Abstract]
-
Cherup L.L., Siewers R.D., Futrell J.W. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
Accepted for publication February 17, 2000.
This article has been cited by other articles:
|
|
|
|
 
D. Mishaly, P. Ghosh, and S. Preisman
Minimally Invasive Congenital Cardiac Surgery Through Right Anterior Minithoracotomy Approach
Ann. Thorac. Surg.,
March 1, 2008;
85(3):
831 - 835.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Li, Y. Liu, C. Yu, B. Cui, and M. Du
Comparison of Incisions and Outcomes for Closure of Ventricular Septal Defects
Ann. Thorac. Surg.,
January 1, 2008;
85(1):
199 - 203.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Oiwa, R. Ishida, and K. Sudo
Systematic Traction Techniques in Minimal-Access Pediatric Cardiac Surgery
Ann. Thorac. Surg.,
November 1, 2004;
78(5):
1856 - 1857.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Bleiziffer, C. Schreiber, R. Burgkart, F. Regenfelder, M. Kostolny, P. Libera, K. Holper, and R. Lange
The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis
J. Thorac. Cardiovasc. Surg.,
May 1, 2004;
127(5):
1474 - 1480.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
